Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure that an allegation of physical abuse involving a resident was reported immediately to facility management and to the State Survey Agency within the required timeframe. According to the facility's policy, all instances of abuse must be reported immediately to the Administrator and to the state agency no later than two hours after the allegation is made. However, in this case, a resident with a history of stroke, paralysis, dementia, and other medical conditions reported that a Certified Nurse Aide (CNA) had thrown them into bed. The allegation was made known to a Registered Nurse (RN) on the day of the incident, but the RN conducted their own investigation and determined there was no reportable occurrence, failing to notify management or the state agency as required. The resident, who was dependent on staff for mobility and transfers due to significant physical limitations, described being roughly handled by the CNA, resulting in their feet being caught in the wheelchair. The incident was relayed to a family member, who then contacted the facility. Despite the resident's report and the family member's concern, the RN did not document or escalate the allegation to the Director of Nursing (DON) or the Administrator on the day it occurred. The facility's self-report to the state agency was not made until the following day, outside the required reporting window. Interviews with facility staff confirmed that the expectation was for all allegations of abuse to be reported immediately to supervisors and to the state agency within two hours. Staff members, including CNAs, nurses, the DON, and the Administrator, all stated that immediate reporting was required by policy. The delay in reporting the allegation of abuse constituted a failure to follow both facility policy and regulatory requirements for timely reporting of suspected abuse.